Thursday, May 8, 2008

Tough Call

[Warning/waiver: Hello, all. I have had to delete the initial opening paragraph to my post, which included general greetings and a brief outline of this last month’s activities, because, as I wrote the post, it didn’t follow that outline at all. Much to my surprise, what follows is an exploration of healthcare on two different levels. Also to my surprise, it has gotten late and I have to go to bed now. But rest assured that I will post more very shortly, and it will be less lengthy and have more pictures! Until then, here you are:]

During the past four weeks or so, we’ve been working on getting our community health program up and running in two new – and very different – communities. In El Brisal, named for its hill-top breezes, we’ve come up against a lot of obstacles. The community is rather new and hasn’t yet developed a well-organized neighborhood council. Our program policies require a strong leadership structure in the community, since a lack of one usually indicates a community unable to take on the responsibility of health promotion and illness prevention themselves. It’s not that people don’t want to be healthier, know more about fever and infection, or learn new water-treatment options – and it certainly doesn’t mean that they don’t deserve these things – it just usually means they are absorbed in the hard work of making their own lives move forward from day to day, and aren’t yet in a place stable enough to take part in an “extracurricular” activity like volunteer work. In El Brisal, we have tried five times to have our initial program-presentation meeting. We have started hours late; we have canceled because no one showed up to our well-publicized meeting; we’ve had people come to ask us to fix the electricity problems, the water problems, the inflation problems, the swamp and mosquito problems…. We have never had more than two people show enough interest or dedication to come to more than one meeting.

This raises a lot of issues I studied in undergrad on a theoretical basis, but turn out to be much more complicated in real life. Big surprise, right? One of these is the issue of healthcare on the individual versus group level. Currently, our healthcare in the United States is focused on the individual – we will pull out all the stops, use whatever tests and resources are available, simply do whatever it takes to see an improvement in the individual patient in front of us, all of which makes for inherently “treatment-focused” care. This kind of care comes with assumptions about unlimited resources, and measures its own efficacy on a case-by-case basis. (This all, of course, really mostly applies to the insured patient who can pay.) On the other hand, a public health approach focuses on the group level. Working under the assumption that there exist limits to healthcare resources, and that these limited resources should be used to achieve the greatest good, this type of care tends to be prevention-focused, and measures its efficacy based on group statistics like a decreased infant mortality rate in a given population.

Both individual- and group-level healthcare have pros and cons. Doing everything in your power to fix the sick person in front of you feels right (and is what we all want when we picture ourselves as the individual)… besides, what would healthcare really be like if tough, ethical, in fact “god-like,” decisions and judgments had to be made about who deserved what and how, where and when. But similarly: What if we worked to prevent the illness that required these drastic treatments, as we so often can? And as moral, caring, and perhaps religious people, aren’t we obligated to think of others, especially the underprivileged groups that are already experiencing a rationing of healthcare that we just don’t see? Lots to think about. And that was quite a crash course… please feel free to respond to/correct what I just described (especially since I’m not even sure if I still speak English anymore).

So back to the matter at hand: I work in community health, a group-level healthcare approach by definition. I have seen first-hand that there are not unlimited healthcare resources in this world. And I have seen first-hand some of the useless and wasteful effects of the individual-approach in this country, as I have seen incredible benefit from health education and preventative measures. But then there’s Kevin:

Kevin is the 14-month-old son of one of the two people who came to several of our meeting attempts in El Brisal. He is interactive and social, and his mother is a quiet, dedicated woman who believes in contributing her time to the benefit of her greater community. They both represent the many wonderful, deserving children and adults in this neighborhood. But she and Kevin – and the rest of El Brisal – will not benefit from our community health program (at least not yet) because the community doesn’t yet have the infra-structure to support it. On a personal level, it is unlikely that I will ever see them again. Isn’t that sad? Aren’t you feeling frustrated? I am.

But now listen to this: The other community where we have started implementing the program is about 15-minutes away (that’s a lot of gas-money, by the way) and is called Los Conucos. In terms of need, it is certainly in league with El Brisal. In fact, as we have discovered in completing our census, hardly anyone knows where to get a free, confidential HIV test, lots and lots of children simply aren’t vaccinated, most people don’t treat the cooking water they draw from their contaminated wells, and the concept of ever feeding an infant solely breast-milk is almost unheard of, let alone doing that for the recommended first six months. But Los Conucos has a well-organized and hard-working neighborhood council, which immediately understood and agreed with the premises of our program. In one meeting we enlisted the support of the community council. In the next we had 25 people interested in volunteering their time as a health promoter. And in the next, all 25 returned and spent half a day being trained in health promotion and getting their neighborhood assignments. In fact, this community is so organized that they have decided to kill two birds with one stone, and have gotten their high-schoolers interested in and committed to being health promoters, instead of hanging out on street corners and in bars. Isn’t that great?! Aren’t you feeling exhilarated?! I am!

Our first meeting with interested promoter candidates

Some high-schoolers stay after to read our Women´s Health manual

But now imagine that you have to choose between these two communities. In a very real and true-to-life scenario, imagine that the Community Health Program of La Clinica Esperanza y Caridad is low on funds. What am I saying, “imagine”? Haha. We do not have the resources to implement this program in every needy and deserving place. We are constantly making decisions like the hypothetical one before us now. In this situation, of course, the clear choice appears to be Los Conucos, where the community is equipped to become responsible for its health status/care, and you can already see the benefits of the program in effect. El Brisal may be ready at a later date, and perhaps we’ll have the funds by then.

But now imagine that the funds are there – now – to implement the program in both communities. So no one will miss out if you start the program in both places… for now. Is it responsible to expend the money, materials, staff, time, effort, on a community where it will most likely yield no result? Especially when it is likely that you can save the resources and use them on another community like Los Conucos? Again, it seems obvious that the responsible thing is to save the money….until you start thinking about the people like Kevin and his mother who will miss out on the information, and continue at higher risk for illness and even death. Don’t all people deserve a chance to be healthy and shouldn’t we do whatever is in our power to improve that chance?

Conveniently, it is part of program policies that we do not start the program and invest the resources in communities without a leadership structure. Phew. Looks like that tough decision has already been made for us. But as I continue in healthcare here and in life, as I engage in the decision-making, in the choosing of who gets and who doesn’t, I just feel pretty unequipped – despite “logic” and “good reasons.” I believe in prevention and community health, but communities are made up of individuals! I know these people. It’s hard.

So this has been long. And there is still so much more to say. I guess the nutshell is this: Life is full of complicated decisions. Healthcare is full of complicated decisions. But it is important that we identify them and think about them, even when there are no clear answers to be found, and even if we are not healthcare providers ourselves. And that’s where I’m stopping for today. I had had great plans for a long, vast post covering many aspects of work and daily life, but this post took a different course of its own. So now I’ll add a warning/waiver to the beginning before I publish it, and call it a night. Happy May everyone - I’ll trade you a mango for a small bouquet of Lilly of the Valley! Enjoy!


Claire said...

Hi Kate -

I can't really even begin to address the frustrations and complications that you are dealing with... But I am consistently impressed with your capability to find hope in those situations. Quite inspiring! By pressing on, you are making positive change (even through your blog!).

You're awesome!
- Claire

Ryan said...

Hi Kate. I find it interesting that the overall decisions of the health care program, and the people you are working with, have a very similar dilemma to the two ways that you describe health care being administered.

It seems that there is a metaphorical relationship where the singular village or town replaces the individual-level heathcare and the decision of how to help the most people and use funds most efficiently would replace a group-level healthcare system.

Weather that's obvious, (or even understandable, with my vast writing skill) is... anyway. Sounds like you are doing fulfilling work and making a difference in people's lives. Super cool.

Ry ry